Laparoscopic management of benign liver diseases: where are we?

Abstract

The role of laparoscopic surgery in the management of benign cystic and solid liver tumours appears to differ according to each tumour type. As regards congenital liver cysts, laparoscopic treatment is now the gold standard for treating selected, huge, accessible, highly symptomatic or complicated cysts. In contrast, the laparoscopic approach is not useful for patients suffering from adult polycystic liver disease (PLD), except for type I PLD with large multiple hepatic cysts. For benign hepatocellular tumours, the surgical management has recently benefited from a better knowledge of the natural history of each type of tumour and from the improvement of imaging techniques in assuring a precise diagnosis of tumour nature. Thus the general tendency has led to a progressive restriction and tailoring of indications for resection in benign liver tumours, selecting only patients with huge, specifically symptomatic or compressive benign tumours or patients suffering from liver cell adenoma. Despite the enthusiastic use of the laparoscopic approach, selective indications for resection of benign liver tumours should indeed remain unchanged. For all types of benign liver tumours, the best indication remains small, superficial lesions, located in the anterior or the lateral segments of the liver. Deep, centrally located lesions or tumours in contact with major vascular or biliary trunks are not ideal candidates for laparoscopic liver resections. When performed by expert liver and laparoscopic surgeons using an adequate surgical technique, the laparoscopic approach is safe for performing minor liver resections and is accompanied by the usual postoperative benefits of laparoscopic surgery. When applied in selected patients and tumours, laparoscopic management of benign liver diseases appears to be a promising technique for hepatobiliary surgeons.

Figures

Figure 1.

Similar appearance on computed tomographic examination of a liver cystadenoma (A) and a hydatid liver cyst (B).

Figure 2.

External ond internal macroscopic aspect of a typical congenital liver cyst (A–D) and a liver cystadenocarcinoma (E, F).

Figure 3.

Poor indications for Iaparoscopic management of congenital liver cysts (CLC) include small, deeply, centrally or posteriorly located or multilocular liver cysts (left column). Good indications are huge, superficial CLC, apparent at the liver surface and located in Couinaud segments Sll to SVI, or posteriorly if bulging (right column).

Figure 4.

Preoperative (A), peroperative (B) and postoperative (C) computed tomographic examinations of a huge symptomatic congenital liver cyst located in segment VIII, treated by laparoscopic fenestration and in situ omentoplasty (arrow).

Figure 5.

Destruction of the cystic wall epithelium by vaporisation using an argon beam coagulator at the end of the deroofing procedure for a congenital liver cyst (A, B): microscopic aspect of the cystic wall epithelium before (C) and after vaporisation (D).

Figure 6.

Authors’ classification of adult polycystic liver disease (APLD): type I APLD represents a valuable indication for laparoscopic fenestration (A, B) while type II APLD (C, D) and type III APLD (E, F) are poor indications for laparoscopic management

Figure 7.

Laparoscopic liver resection for a liver cystadenoma. (A) Preoperative computed tomography; (B) intraoperative view before resection.